Tuesday, December 27, 2011

Doc Beggar's Little Pal


I'd almost resolved 2012 would be the year of the new computer. With graduation on the horizon and residency afterward, one starts thinking about transitions, and whether it's time to bite the bullet and upgrade. On top of it all, my laptop has had "issues" lately, At first, it was a malfunctioning touch pad requiring me to hold down the "alt" key in order to move the cursor. Then the "d" key began producing "da" each time I struck it. Finally, the "a" key joined in, sometimes psychotically producing a line of letters that ran off the page and sometimes refusing to work, period, no matter how hard I pressed. What to do?

Well, my computer is off-warranty, restricting my options from the outset. Having worked on my own car in the days when engine size was measured in cubic inches, I decided to search the Dell website and see if I couldn't fix the situation myself. That led to installing a host of new drivers, none of which had the slightest effect on the keyboard, naturally. So, I reinstalled the original keyboard driver two or three times from the CD that came with my computer. And did that work? Uh, no, as a matter of fact, it didn't.

Next, I called Dell tech support. Actually, my first instinct was to call, but I assumed they'd tell me my warranty had expired and there was nothing they could do unless I had a credit card handy. Wrong again, they were nice enough to take a look via computer sharing before politely informing me I needed a new keyboard. Not a new one exactly, because my computer is so dated, new parts are no longer produced. They meant a rebuilt keyboard, i.e. newer than the one I had.

All the while, I'm still thinking about a new computer. I felt badly about it because this one and I have been through a lot. We're veterans of three, going on four, years of medical school and together we've gotten a book published and written several hundred blog posts. That's a lot of history, you know? The thought of reformatting "his" hard drive and erasing six years of my life, despite having saved the data on a backup drive, didn't sit well. It was too much like breaking off a friendship when the going gets rough. Besides, that's when friendship counts the most or so I believe, anyway.

A good night's sleep later, I decided to make a final stab at Google, this time searching the error code I'd gotten from running a diagnostics program. The result indicated a stuck key. Can it really be that simple? I wondered. After prying the cover off the "a" key and thoroughly cleaning its constituent parts, I restarted the computer, crossed my fingers and held my breath. Not only had the "a" recovered its sanity, the "d" no longer typed "da" and my touch pad functioned normally. Forget a new computer, the one I have is "back" and I'm happy as a kid who's discovered reindeer hoof prints in the snow on Christmas morning.

Sure, fixing the problem on my own felt good, but what delights me more is not having to replace Doc Beggar's Little Pal, as I refer to it. It's sort of like a Guild steel-string guitar I packed around throughout college, seminary, graduate school, and beyond. Despite being battered and scratched, it plays well and its sound reflects the depth and character of mature wood. I could have bought another, I suppose, but even if I had, I'd still play this one. We've traveled too many miles and shared too many lonely nights, to call it quits over a few blemishes.


(Creative Commons image of a Guild headpiece by bijoubaby via Flickr)

Sunday, December 25, 2011

A NORAD Christmas Reprised

A relative of mine once said, a little sadly, "Christmas is for children." I was young at the time, how old I'm not sure, but I remember thinking, Christmas isn't for adults, too? Looking back, I think he must have felt he'd lost something along the way, a loss he felt most acutely at Christmas.

Entering the holiday season with baggage from long ago isn't unusual. Often, adults find tears come as easily as smiles. The Christmastime when I was young, the magic and the wonder, but colors dull and candles dim, and dark my standing under,
isn't just a song lyric, it's a reality for many. They're the kind of things that got me thinking, back in 1999, about Christmas when I was young and how my parents and I spent evenings like this one with my aunt and maternal grandmother. One thing led to another, and the story that follows was born. Some elements are true in the sense they actually happened, others are made up, expressing wishes of the heart as much as anything.

It's title stems from one of those real events, the night I first heard of NORAD tracking Santa. I remember it as though it was happening at this very instant and it's something I'll never forget. I'm sure you've had similar experiences that you treasure in much the same way. Originally posted at Christmas in 2009, I'd like to offer it again with the hope that this Christmas is all you've dreamed it could be.

A NORAD Christmas...

Christmas Moon 2007
I can't help it -- oh, I guess I could, but I don't want to -- Christmas is my favorite season. Somewhere around Halloween I come down with a serious case of "holiday fever" and don't recover until well after New Year's. Each holiday brings a spike in my temperature until, by December 25th, I feel more alive than at any other time of the year. It's as though I'm caught up in something that has a life of its own: a season of changes, a time for new birth, a time for starting over, for filling Life with mirth.

One particular Christmas Eve forces itself into my memory each year. It beg
an as did most when I was a child. Early in the evening, my parents and I gathered presents, bundled up against the cold, and drove to the home of my maternal grandmother, miles away in the city. We lived in the country and the city lights formed a dim halo about the crest of the hill that rose slowly from our front door. The night sky was clear and starlight glittered on the newly fallen snow coating the farms and fields along our way.

My grandmother lived in a two story, white stuccoed survivor of the Roaring Twenties, with a huge arched window facing the street. In anticipation of our arrival, she kept the house dark except for the lights from her tree pouring through the window and onto the flagstone walk at its feet.

I had scarcely gotten out of the car when my maiden aunt burst breathlessly from the house. She had not-quite-flaming red hair, and when I think of her now, fire engines come to mind. My aunt displayed incredible energy in all she did and whenever a problem threatened to burn out of control in my life, she was always there with her "fire hose" to lend a hand. Sweeping me up in her arms, she asked, "Did you write your letter to Santa? Did you mail it in time?"

"Yes! Did you?"

"Oh, yes, I mailed mine a week ago!" she replied, her eyes bright with laughter.

Greeting my parents, she ushered us into the house, then rushed from lamp to light switch, flooding the old house with light. My aunt loved Christmas and spent days preparing for the holiday. The dining table would be laden to overflowing with cold cuts, marshmallow salad, peanut brittle, almond bark, and my favorite, spearmint ribbon candy. With carols playing on my grandmother's aging Telefunken stereo, a gift from her youngest bachelor-son, we visited, snacked, and opened presents.

Finally, my grandmother growing festively weary, we gathered our coats and stepped out into the night for a final glimpse of the stars before driving home. My aunt leaned down and whispered, as always, "Do you suppose this will be the night we see him? I'm listening for sleigh bells..."

The long drive home made me sleepy and I'm sure I must have dozed because the next thing I knew, my father was carrying me into the house. The hour was late, but we stayed up to watch the news and relax. I sipped hot chocolate and read the comic pages from the morning paper when my father nudged me.

"Listen to this!" he said.

I stopped reading and looked up as the announcer reported that an unidentified flying object had been sighted over the Arctic and NORAD, the North American Aerospace Defense Command in Colorado Springs, was tracking it. I became immediately excited because I loved science fiction and was certain it had to be an alien craft.

"Just wait," said my father, "there may be more."

Sure enough, moments later, the announcer interrupted the weather segment with an update. "NORAD reports the object sighted over the North Pole has been identified by Air Force jets based in Alaska. It is, in fact, Santa and his reindeer, and the pilots have been instructed to escort him safely into United States air space."

I looked at my father with what must have been absolute rapture. Not only did my aunt and I believe in Santa Claus, so did the Air Force -- more than that, they'd actually seen him! If I might have ordinarily had difficulty sleeping on Christmas Eve, you can be sure I had even more that night.

A long time has passed since I've spent a happy Christmas with my aunt and grandmother. Both of them are years gone and those evenings live in memory. Thankfully, however, some things don't change. After Christmas Eve candlelight church services, my wife, our children, the dogs, and I curl up with hot chocolate by the fire to watch the late news. When the announcer faithfully reminds us that NORAD has sighted a sleigh in the northern sky, the kids turn to face us with eyes like starlight and smiles even brighter.

And every year, once the house is quiet and the kids asleep, each one snuggling a well-loved dog, my wife and I step outside for a final glimpse of the stars, and we wonder, will this be the night...?


(Copyright (c) 2009 by Patrick W. Conway)
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Saturday, December 24, 2011

"Merry Christmas," She Said.


Not wishing to remove my gloves in the cold, I said, "I'll catch you on the way out." It would be simpler, I thought, to keep my wallet handy once I'd finished at the cashier's. She smiled and nodded, not missing a beat, our conversation another verse to the song she played inside her head.

I didn't have to say anything; her back was to me, I could have walked on, completed my business, then done as I intended. No one needed to know; none would be the wiser.

Except that I wanted her to know because so many just walk on by. I almost forgot myself, until the last second when I saw her again and remembered. I marveled at her patience, at her consistency. It wasn't like she expected everyone to stop; only those who were supposed to. She was on her appointed rounds, waiting for her people to show up, even if they didn't realize they were hers until that very moment. In the meantime, she kept on, ringing what I heard as Jingle Bells and she maybe something else, her eyes peeking over the rim of a muffler wrapped round her face, twinkling in good faith.

I would get impatient, I'm sure. Impatient, disgruntled, discouraged and then cynical, passing judgment, playing God. It would be easy to do, to forget how easy it is to be guarded in times like these, to blame the unfortunate for their misfortune, to cross to the other side of the road like the Priest and the Lawyer once did and a Good Samaritan didn't.

A Samaritan, by the way, who wasn't like we paint him, one of the good guys going about doing good deeds at Christmas, someone you'd like to have living next door or upstairs. He was a Black man in 1950s Alabama who dared touch a White woman who'd been raped and left for dead. Or, maybe she's homeless, living in a tent constructed from cardboard boxes. The Good Samaritan was like that, unacceptable by the book, but caring anyway.

She was also a Salvation Army Bell Ringer on a frigid Portland morning waiting for me to step up and be counted. To stuff a bill in her bucket. To render aid. To follow her example, to not cross the street and walk on by.

"Merry Christmas," she said.


(Creative Commons image by miliu92 via Flickr)

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Sunday, December 18, 2011

It Felt Like Warp Drive


It reminded me of a scene toward the end of Star Trek III: The Search for Spock. You remember, the one where Kirk and Crew hijack the Enterprise to rescue Spock, whose body has been re-animated by the Genesis Wave that was set off on the Genesis Planet. I was tempted to say, "re-activated," but that sounds too mechanical, sort of what you'd do to Spock's successor, Data, in the second generation Star Trek. I'm glad the third generation is really the first generation re-discovered. I enjoy Jean-Luc and all, but at heart, I'm a purest.

It's the same film, by the way, in which Dr. McCoy delivers a line I'd love to have written. The Enterprise is going down in flames and Kirk says, "My God, Bones, what have I done?" McCoy replies, "What you had to do. What you always do. Turn death into a fighting chance to live." I think that's one of the best lines in film, maybe in literature, maybe even in history. Sigh.

Anyway, where were we? Oh, yeah (blush), sorry for the digression. So, I woke up this morning, somewhere around way-too-early with the sensation of cold on my face, nose to forehead. It was the same kind of cold I've experienced on winter Scouting trips, and so have you, if you've ever gone camping or backpacking and felt nature's frosty, chilly, barely-dawn breath on the portion of your face that doesn't fit inside your mummy sleeping bag and asked yourself, Why was it, once again, I thought this was supposed to be fun?

Well, at first I thought a window was open and when my pager sounded its dweedle-DEE-de rendition of reveille at 5.30 (I've got to turn that thing off, it's Christmas vacation after all), I summoned the courage to get up and close it -- the window that is -- except it was already closed. Next thing was to head for the bathroom and then turn up the thermostat. Except, instead of its familiar varoom, the furnace only clicked.

Mm.

I've heard this before, I thought, and decided it meant we had run out of fuel oil. Except the date on my latest bill said we'd just gotten a delivery. Nobody uses 150 gallons of oil in four days. Not even in Maine in the dead of winter unless they're drinking it. Since I wasn't, in a flash of medical student intellectual acumen that would give Mr. Spock Logic-Envy, I concluded it had to be the furnace. Unbelievable.

With visions of phoning the repairman dancing in my head and flashlight in hand, I stepped into the dank depths of the basement and weaved my way through the hanging gardens of cob webs to face the music. A glance at the breaker box confirmed the furnace, installed years ago by the Dead-Head Oil and Gas Company (owned and operated by a Grateful Dead fan, naturally), was getting power, so what now? Almost fresh out of ideas I noticed a little brass plaque detailing instructions about what to do when the furnace hasn't started up. Well, duh.

Step one, check the power. Done that. Step two, check the oil. Done that, too, please tell me something I can't figure out on my own. Step three, press the reset button -- only once. What happens if you press it twice, I don't know, but I wasn't interested in finding out. As I reached my finger toward the single button I could find, it came to me. This is just like Mr. Sulu, Mr. Scott, and Mr. Chekov, trying to decipher Klingon in order to engage warp drive at the end of Star Trek III. The Genesis planet is exploding and Larry, Moe, and Curly are at the helm. Finally, Sulu throws a switch and announces, "Sir, if I'm right, we have warp drive." Kirk responds, "Go, Sulu!" and they're off.

And so was my furnace. On, I mean. Not off, not as in warp drive or bound for Vulcan, but on, as in working. Okay, maybe you'd have to have been there. It sure felt like warp drive to me, though.


(Non-free low resolution image from Star Trek III: The Search for Spock, by illustrator Bob Peak, copyright presumed to be held by Paramount, 1984, used to identify the film cited herein, via Wikipedia)

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Saturday, December 10, 2011

Door Number Three

Newborn child, seconds after birth. The umbili...Five days ago, six if you count Monday and orientation, I walked onto the obstetrics unit, knowing little more than Prissy (Gone With the Wind, 1939), who freely admitted she knew "nothin' about birthin' babies." I guess that means I knew next to nothing, which is okay; if I knew at the beginning of this rotation what I hope to know at the end, there wouldn't be much reason for what comes along in between, would there?

As it stands, I've already learned a few things, among them that I'm not inclined to drop a slippery newborn despite the fact, as a kid playing Little League, "Butterfingers" could easily have been my nickname. There's something about holding a baby who's just taken its first breath, that makes you hold on for dear life. Maybe it's parenting instincts kicking in, but the thought of losing your grip doesn't cross your mind. Holding them close with a quick, welcome-to-the-world snuggle in the crook of your arm, while passing them to the NICU (neonatal intensive care unit) team, you bet, but letting them slide through your fingers? Uh-uh.

And then, there's the matter of learning about the mess. Childbirth really is messy business. Television prefers spit and polished, shiny clean new babies who don't make anyone squeamish. Not so Mother Nature. There may be some blood, especially if junior's exit from the womb produces a tear in mom's vagina. There's amniotic fluid when her water breaks, though that usually occurs earlier, unless she's having a C-section, in which case the flow of amniotic fluid is more like a flood. To top it off, there's meconium -- baby poop -- mixed in for good measure. Martha Stewart would cringe.

Honestly, though, I don't mind the mess. Life is messy. Personally, I think trying to eliminate the messiness nudges more people toward neurosis than the other way around. It certainly is a driving force in narcissism, where the appearance of perfection is all-important. Babies have an entirely different perspective. Forget all that other stuff, okay? Mom was toasty warm, will someone please wrap me in a blanket? Ah, there we go, that's better. Mm. Thank you very much.

What I'm particularly enjoying about this rotation thus far is the tacit understanding that some things can only be learned here. Internal medicine teaches you how to write a good clinical note, surgery how to behave in the OR, pediatrics how to deal with kids and parents, psychiatry how to manage things going wrong, and then rural and family med puts it all together. None of them, however, specifically target birthing, prenatal care, or women's health (gynecology). So, in a sense, it's expected that a student is literally starting over at the bottom. You can use skills gained elsewhere to a certain extent and yet, so much is totally new. Every day is pregnant (pardon the pun) with possibilities and you never know what's waiting behind door number three.


(GNU Free Documentation image of a brand new newborn via Wikipedia)

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Saturday, December 3, 2011

No Claims to Courage


Well, as of yesterday, surgery is over. I passed my exam, packed my bags, and said adios to the little two story house on the banks of Long Pond in central Maine, that has been home away from home since mid-October. Thursday marked my last shift on the surgical unit and it felt wistful, saying goodbye to people who've become coworkers as much as teachers these past six weeks.

Technically speaking, my instructors have been surgeons: general surgeons, urologists, obstetrician/gynecologists, orthopedists, and neurosurgeons. Quite a range when you consider the size and scope of the hospital. But the nurses and surgical techs were teachers, too, and good ones. And I ought not forget the anesthesiologists and nurse anesthetists. Together, they taught me how to behave as a member of a surgical team.

It has to be difficult, being regular staff and having a newbie walk through your doors eight times a year. Friday, one leaves and Monday, another shows up. Friday's guy has finally figured out how to find the bathroom without having to be shown and Monday's doesn't know what a bathroom is yet. It's not quite that bad, but you get the idea. There's a constant flow of change. Students are a "complete unknown," as Dylan put it, rolling stones gathering as much moss as they can before rolling on.

When I began this rotation, it was with the understanding that a community hospital wasn't exactly the best place to learn about surgery if I wished to become a surgeon. Opportunities for observing and participating were, of necessity, directed toward the ordinary or the mundane. I suppose that's true, but I gained a great deal in spite of the presumed limitations. One of my pastoral mentors reminded me, as I was leaving for seminary, "You can learn something from every preacher, so pay close attention." That advice holds true for rotations and this one was no different.

For instance, I learned how to intubate, i.e. insert a plastic tube into the mouth of an anesthetized patient, past the epiglottis, locate the vocal folds, and slide the tube between them, ensuring an adequate airway during surgery or at other times when a patient needs ventilatory support to breathe. I learned how to place a laryngeal mask airway tube when intubation wasn't necessary. And I learned how to start an IV line. All good tools to stow in my doctor's bag alongside the reflex hammer and stethoscope.

I learned how to take a leap of faith, not once but twice, by incising a patient's belly with a knife sharp enough to cut just by looking too closely at the blade. I also learned the cost of hesitation. Surgical time is billed to the tune of twenty-five bucks a minute. With a mere 60 seconds constituting each minute, one second wasted in unnecessary indecision is accompanied by the sound of 42 cents clinking down the drain. Standing alongside my patient I had 84 cents max to decide whether I had the guts for this kind of work or not. You wouldn't think faith could be thus quantified, would you?

I think my father would have enjoyed talking about this rotation. He knew some experiences have to be lived to understand, but he'd encourage me to try, anyway. Just the effort, sometimes, takes us places we'd never visit otherwise. Incising a half inch long swath into a belly that had held children cut deeply into my own fears. Of what, I'm not sure, but I came out of the surgical suite feeling braver than when I went in. e.e. cumings wrote, "
It takes courage to grow up and turn out to be who you really are." While I make no claims to courage, I do think I managed to do some growing up the last few weeks and I have a lot of people to thank for it.



(Photo of Long Pond at sunset copyright 2o11 by the author. Like a Rolling Stone, words and music by Bob Dylan, copyright 1965)

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Saturday, November 26, 2011

Not Exactly "Friends"


When and where I grew up, a person rarely heard the sound of gunfire. In fact, I can only recall a single occasion when I heard it within the county limits. My father was boarding a horse for a friend of his who was an avid hunter. One afternoon, concerned his new horse might be gun-shy, he and my father led the horse into our pasture and the friend fired his pistol into the ground. His horse just stood there, apparently unimpressed, waiting to be released so he could return to grazing. Why shoot into the ground? Well, despite the fact that terrorists are always firing automatic weapons into the air on film, in reality that's not a wise practice because what goes up will inevitably come down, including bullets.

So, that was the only time. Hunters eager for deer or elk had to go up into the mountains to find them and those who sought ducks or pheasant, to eastern Colorado. The fact is, there were laws prohibiting the discharge of firearms near populated areas which, if you think about it, is a wise practice. Every year there are stories in the news about someone mistaking a partner, cow, or dog for deer or moose. How you get a moose from a dog, beats me, but maybe at distance Snoopy looks that big. Anyway, s/he hears a rustling of leaves, the snap of a twig, they turn and squinting through the trees, spy a shadowy figure. The thrill of pursuit coupled with the release of adrenaline takes over and you can guess the rest.

When I relocated from Maine's seacoast, I was informed, "Oh, now and then, you might hear a gunshot or two," since this is fairly open country and Maine law permits shooting on private land. To put it another way, were I so inclined (which I'm not), I could sit comfortably in my lawn chair on the front patio with my father's western-style .30 caliber carbine across my lap and wait for the deer who gobbles up my apples to wander into the crosshairs. Either that, or I could purchase a shotgun on the internet for next to nothing and sneak up on the flock of turkeys that also feed freely on my apples to provide next year's Holiday meals. It would all be perfectly legal and conveniently culturally-sanctioned.

Except for that darned, interfering Super-Ego (Freud's term for moral and personal conscience) of mine. I don't generally shoot at friends unless they really, really, really, piss me off and then I prefer to throw pies at them. I'm joking (even about the pies). Truly, I am. Please, pretty please with maple sugar on it, don't call the FBI ("Honest, Agents Sculley and Mulder, it was only a literary device, you know that from the lines the two of you have to memorize, right?"). Well, while we're not exactly what you'd call "friends" -- I haven't invited him in for coffee or tea with late season apples lately -- I do like seeing Bambi wander through the hayfield, munching freely at will. I also like the turkeys, porcupine, and the other wild critters who seem to think this is their farm and they permit my presence, not the other way around. Maybe I'm softheaded in a hardhearted world, but it seems only reasonable to live in consideration of those who were here long before me and, no doubt, will continue to be once I'm gone.

Now, fair is fair and I don't want anyone to think I have something against my neighbors or anyone else who hunts, because it's not like that at all. True,
I'm still not fully accustomed to being awakened on weekend mornings by what I'm convinced is an M-16 going off within walking distance of my house. If it was 1772, when this community was founded, I'd take my trusty long rifle down from over the fireplace and like any other responsible farmer, parson, or whomever with a family, head for the woods imitating Hawkeye from Last of the Mohicans. But this is 2011 and, like I say, I'd rather not shoot at friends or a reasonable facsimile thereof. As things stand, I'll wear orange as a precaution while cutting firewood or walking the dogs, that's not a problem. It's nearing January, it will all be over soon.


(Creative Commons image and Bambi and Thumper by Jaded Jeremy via Flikr)

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Thursday, November 24, 2011

Gratitude


Thomas Aquinas stained glass window.
St. Francis of Assisi knew gratitude was good for us long before this month's Harvard Mental Health Letter added its two cents, but isn't that the way it usually goes? Evidence follows intuition. Well, according to my friends at Harvard, gratitude helps make us resilient. In fact, it's one of many things that have that effect. For instance, working at something you love rather than working less, having a sense of life purpose, giving for no other reason than because you can, forming and maintaining meaningful relationships, and possessing the confidence to steer your own course, also render a person more resilient in the face of whatever life throws at us along the way.

Resilience doesn't mean resistant, it means durable. Resistance can carry the connotation of immunity to injury. Resilience and durability are fluid concepts that describe those who endure what Hamlet called, "the slings and arrows of outrageous fortune," and come through scathed and scarred, perhaps, but not embittered. Resistant, to me, is a wall; resilient is a membrane, tough and tender, alive, open to experience.

Thinking about gratitude and the resilience it engenders, on this Thanksgiving eve, I'm grateful for a young woman who became the first live human in whose body I've inserted a scalpel to make an incision. She was unconscious at the time, "thanks" to the wonders of anesthesia, but I was sufficiently aware for both of us and so grateful for the privilege she'd granted, I was close to tears when the final sutures were in place. It felt as though I was incising something from my own life (a topic for another post) as much as something from hers.

I feel grateful for my entering medical school class, a group of people, all of them younger than me by months to years, in whose company and because of whose support, I've somehow managed to come this far. They play hard, work harder, each having sojourned in at least one of Dante's Twelve Circles of Hell, and survived with hope and heart intact. It's a privilege to be numbered among them.

I'm grateful for the snow that began falling overnight, the plow that woke me at 4.06 AM and the hunger that followed in its wake, dragging me from the warmth of bed to face the chill of my upstairs room. I'm glad I raked the leaves crowding close to the kitchen door and straying carelessly onto the driveway last night, so that shoveling snow this morning was easier. It was dark in central Maine, dark and cold, and the drive to my hospital slickly hazardous. I'm grateful my CRV takes little note of the weather, embracing ice and snow as a challenge, instead of a threat.

I'm even grateful for the fuse that blew in the kitchen this morning. Power outages in the forecast, I made coffee last night and put it in the fridge -- cold coffee being better than none. Warming it in the microwave was too much too early, it seems, so I had to take flashlight in hand and brave the depths of the cellar I've considered the ghastly realm of goblins, spooks, and creatures unspeakable. It was nothing of the sort, but gazing into the black basement of our creakily ancient temporary housing, my imagination ran rampant. Yoo hoo, Stephen King, are you down there?

Some things only a fool or a madman would be grateful for, but it's the trivial we most often overlook. Those insignificant moments of inconvenience over a blown fuse teach us how to draw upon gratitude when we need it the most. Those moments that remind us that faith, hope, and love can be found anytime, anywhere, and not merely the one day of the year we remember to give thanks. Whoever said, it's the little things that count, wasn't kidding.

Happy Thanksgiving!


(Creative Commons image of St. Francis of Assisi via Wikipedia)

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Sunday, November 20, 2011

Paying Your Dues or to Paraphrase Charlie Brown...


"Doesn't anyone know what surgery is all about?"

I've been wrestling with this question for the past four weeks and it hasn't been an easy match. I thought I had it pinned a couple of times and then it squirmed out from under me. Think about those occasions when you've watched Olympic wrestling and you'll get an idea what I mean. Both shoulders have to touch the floor at the same time for a winner to be called and close isn't close enough.

For my friends who are surgeons-in-residency or our preceptors, the answer is probably straightforward, surgery is about cutting. Suggesting there is a deeper philosophical significance for what they do is likely to trigger a smile, a good natured nudge in the ribs, and, "There Beggar goes again." Sorry, guys (a non-gender specific term for me, inclusive of gals, guys, and a dog or two thrown in for good measure). I can't help it. Finding meaning is what I do.

That said, I'm really not referring to surgery as such, but to basic surgical training, i.e. third-year surgical rotations. The former is way out of my league, but regarding the latter, to borrow from Country singer/songwriter Garth Brooks, I'll "choose to chance the rapids and dare to dance the tide." But as anyone knows who's rafted the Colorado or any other big river, you've got to have a guide who knows the water, and on this chilly November morning, it's my father's turn to take the tiller.

What does a saddlemaker have to do with surgery? Aside from the fact that he was well-acquainted with sharp knives and slicing through flesh? He knew what it was like to be an apprentice. You see, at the end of World War II, when he was discharged from the Army, the way someone pursued a career in saddle making was by apprenticing themselves to masters of the art. These were men, predominantly, who began honing their craft well before my father was born. They started out precisely as he was expected to, by sweeping the shop floor, watching and listening, doing a lot of what we call in medicine, "scut work," and waiting his turn.

It was frustrating, he told me years later, because he wanted to learn and surely, that was best done by doing. Being told he wasn't ready to "do," that he'd be told when he was, tried every ounce of patience he could muster. Slowly, over time, he was allowed to take carving tools and scrap leather home to practice and eventually, one thing led to another. It was very much like a third-year surgical rotation, I've decided.

For my part, I spend a great deal of time watching and keeping my hands to myself. Students have two primary tasks in a rotation like this. The first is learning how to refrain from contaminating yourself or anything and anyone else in the operating room, no small feat in itself.
One false move and you've touched something you shouldn't or bumped into someone you wish you hadn't. Mikhail Baryshnikov would cringe at the choreography.

The second task is harder, perhaps hardest of all. It entails practicing knot tying and suturing at home, standing next to the surgeon for what feels like forever, waiting to be invited to participate at the most rudimentary of levels, i.e. holding a retractor, snipping sutures, or if you're lucky, stapling an incision closed. If you're really lucky, like I was the other day, you get to guide a laproscopic camera, which has been inserted through a plastic tube called a trochanter, into a patient's abdomen, while your preceptor removes an inflamed gall bladder. It felt like I was moving up in the world.

Seriously, you want very badly, as a student, to do something that matters. It's one of the primary reasons we attend medical school in the first place. In a specialty like surgery, however, and truthfully, in all medical specialties, we have to learn the value of humility. We're students, after all, and the only proficiency we possess at this point in our education is that of memorizing large quantities of material, a skill which, our preceptors inform us, has limited applicability in the world of real medicine. It's all about learning how to wait your turn and appreciate every opportunity to do more.

Horace Mann wrote, "More will sometimes be demanded of you than is reasonable. Bear it meekly, and exhaust your time and strength in performing your duties, rather than vindicating your rights." Eventually, your time will come and those who've witnessed your commitment and devotion, will remember you as one who worked your heart out and didn't complain. As my father would say, it's called paying your dues.


(Creative Commons image of Charlie Brown shopping for a Christmas tree by KIT via Flickr; The River lyrics copyright by Garth Brooks)

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Sunday, November 13, 2011

I Heard Sleigh Bells


She must have been about four, old enough to go shopping with mommy but still too young to make the entire trip without being carried to the car afterward. She was holding her mother's hand, waiting, as was I, for the Portland Williams-Sonoma to open. If the holidays are magical -- and for me they definitely are -- Williams-Sonoma has a corner on the market. From peppermint hot chocolate to china to cookie and pie cutters (my target purchase this time) -- I wonder sometimes if they don't have a direct line to the North Pole.

I realize Thanksgiving is a couple of weeks off, and you're right, it really is too early to be writing about Christmas. I mean, Madison Avenue is bad enough. Turn on the tube two days before Halloween and from the ads, it appears Thanksgiving is nothing more than a minor bump on the road to December 25. But what was about to happen in front of Williams-Sonoma would be enough to make even the most jaded forget about the date and simply be glad the Holidays are here at last.

I was standing with my back to a long hallway leading to the mall offices, preoccupied by my sweet, diminutive fellow watcher and waiter and her fascination with the window dressings. A toy train bearing the name, The Polar Express, rolled round a track decorated with artificial pine bows, green ribbons on red packages, and a tiny town replete with snow-capped mountain. She couldn't steal her eyes from it and neither could her mother -- there they were, two little girls, hand in hand, riding The Polar Express.

Suddenly, I heard a loud, "Ho! Ho! Ho! M-e-r-r-y Christmas!" and quickly turned to see Santa Claus step from the hallway into the mall. Oh yes, you bet I smiled and waved, I never miss a chance. He smiled and waved back, then greeted other shoppers who stopped at the sound of his voice to wave.

Then, I heard something else, a rapidly indrawn four-year old breath that made me look down. With eyes like saucers, she whispered in awe, "S-a-n-t-a." At first, I wasn't sure how it would all unfold -- did he notice her? Of course, he did, he's Santa, he knows when we are sleeping, he knows when we're awake -- not a child on the planet goes unnoticed by him and that includes this one. His two female elvish helpers continued on to his "workshop," unware he'd halted in front of Williams-Sonoma and knelt down on one knee.

He reached a mitted hand to his face, thoughtfully stroking a beard I'm absolutely certain had to be real, and softly said, "Merry Christmas, Jennie." She looked up at her mother, whose face was a study in amazement, then broke free and ran into his arms.

I didn't hear what was spoken, that's between she and Santa, and maybe nothing was. Maybe her actions said everything. I know they spoke clearly enough that when he released her and tenderly touched her hair, rising to his feet he looked at me with eyes moist with tears. Yes, Virginia, Santa has a heart, you can be sure of it.

Something told me only a fool would let this moment pass, so I followed after him and laid my hand on his shoulder. "I'm sorry to intrude, but..."

He interrupted me and said, "You want to know how I knew her name. Well, Beggar -- yes, I know yours, too -- after a few hundred years at this, you start to develop a pretty good memory. Merry Christmas." Then he smiled once more and winked.

I could have sworn I heard sleigh bells as he walked away.


(Creative Commons image by dkjd via Flickr)

Sunday, October 30, 2011

Things Dads Do


For a long instant, it felt like Thanksgiving this morning, stepping into a warm living room from the chilly garage where I keep my ready access firewood. With four inches -- nearer six or eight if it was powder -- of firmly packed, heavy, wet snow covering the hayfield, it looks like Thanksgiving. It also looks like a few of the Halloweens of my youth when the end of October mistook itself for the beginning of winter. With a fire softly burning (thanks, JD, for the image) in my study...by the way, we didn't have a fireplace when I was growing up, have I told you?

Our house was small -- three bedrooms, one bath, kitchen/dining and living room, all heated electrically. The closest we came to a fireplace was a small wood-burning stove in our unattached garage that my father used as his saddle shop for several years. Hardly a stove, it was a twenty-five gallon oil drum turned onto its side with a door cut into one end and four welded feet. How he worked out there, winter after winter, is a testimony to a father's love and determination.

I split firewood for him. I remember grousing about it at first, as any kid might, torn from afternoon cartoons to trudge out to the woodpile near the barn. I'm supposed to play, not work, I thought. He overlooked my complaints and taught me how to set up a block of wood, take aim for the middle, and swing without missing. It wasn't long before I began enjoying standing there in the snow with my axe and carrying armloads of split logs into the shop, losing myself in a "living-on-the-ranch" reverie. Writing about all this, I recall a day when I grew up a bit, realizing how my "work" kept him going. I must have been around nine or ten, but I began appreciating my father more than I had before.

Shared tasks, working together, those were his values and he passed them along to me. He was raised in a time and place where everyone had a task and everyone contributed to the family's welfare. He and his siblings had chores, a word one rarely hears anymore and tends to be associated with black and white reruns of old western television shows like The Rifleman on AMC. When used now, it's often in the pejorative sense, life is a chore. And some of his were all of that, especially when he was too young to ride after the cows and had to content himself with milking them, instead. Reality fails to imitate art every now and then.

He wasn't heartless about chores, though, and perhaps that comes from his own experience. One afternoon after school, he'd been too busy to cut wood into sections as he usually did, leaving them for me to split. So I started in with my axe, intent on doing both the man's job and the boy's. He came out a short while later and in a gentle tone he reserved for just such moments, told me I could stop, he had enough wood for now. I was hesitant -- the wood box was nearly empty as anyone could see -- but he assured me he was fine and to go on into the house and get warm, The things dads do.

A person has to wonder where the desires of the heart come from. I still love fireplaces and going out into the forest to cut wood. The axe of my youth has been replaced with a splitting maul, five pounds of steel at the end of forty inches of Ash. There is a sectioned tree trunk, well over a hundred pounds itself, sitting in the garage, the legacy of the doctor who lived here before me, that is our common chopping block. The open rafters are high enough for a full-armed swing.

Sheltered from the weather, it's not the barnyard of my childhood. Nor is my work that of my father. But the appreciation for a warm fire on a cold morning we share, as well as the effort to bring it to life. From whence comes the desires of the heart? I can't always say. What I know with any certainty is, I can't plunge my maul into a block of wood without thinking of all those afternoons, splitting wood in the snow, and my father who taught me how.



(Creative Commons image by Gadget_Guru via Fkickr; "a fire softly burning," Back Home Again, words and music by John Denver, copyright 1974)

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Saturday, October 29, 2011

First Assist

SurgeryMore years ago than I like to advertise, I was flat on my back in a hospital bed, awaiting surgery for kidney stones. It all began on a typical July 4th weekend in northwestern Colorado, visiting family and fishing in the high country. A delightful lunch of cutthroat trout cooked over an open fire was followed by nausea, vomiting, and abdominal discomfort that puts the P in pain. The local ER doc diagnosed a renal stone and I began seeing a urologist in Denver the next week.

As we say in medicine, my initial treatment was conservative, i.e. reduce calcium intake and drink water or cranberry juice like it's going out of style. At that time the theory was, my kidneys were less adept at eliminating excess calcium, so by flushing them with clear fluids, we'd rinse them of the offending chemical. It was a good theory; the problem was, it didn't entirely work, resulting in my first exposure to surgery coming from the patient's side of the operating table.

I spent this past week, and will spend the next five weeks, on the surgeon's side and believe me, that's a whole lot more fun. Not that I minded being a patient, but the lessons I learned have stuck with me. For instance, there's nothing like being at the mercy of the healthcare system to teach future doctors to pay attention when their patients speak. It's one thing to get report of 522b's requests for morphine and quite another to have been 522b, in severe pain, and have to wait -- in pain -- for the hours to tick away like days before the next round of medications arrives. Thanks to the gravel pit that collected in my left kidney, I know what this is like.

What makes the surgeon's side of the table more enjoyable -- apart from the absence of pain -- even for this incipient psychiatrist, is the fact that you're delving into live anatomy. For all the times you may have laid scalpel to preserved, leathery cadaver flesh, when you insert your fingers into the warm open incision of a living person, you've got to experience a mix of awe and fear. Fear that you'll do something harmful and awe because you're in a position to do so, probing where no one has gone before. It's enough to make the crew of the Enterprise envious.

My week, as do most, began with Monday -- orientation, a meet and greet with the staff, butterflies in the stomch. The next four days were spent in the OR from near dawn to mid-afternoon, when the surgeons head off to do office work and I'm left on my own. This
rotation is largely self-directed and I have the freedom to pick and choose the procedures I find most interesting to scrub-in on. Since I'm working in a community hospital, I won't see cardiac or severe trauma cases -- we don't have the ICU facilities for major surgeries like those -- but I'll definitely see the kinds of things most of my future patients will experience and that's what matters. Naturally, I'll scrub-in for all those performed by my primary instructors, but I can also work with any other surgeon who's willing to have a student along for the ride.

It was the latter that led to another first this week, an opportunity to act as First Assist, the individual who stands opposite the surgeon, ready to offer whatever assistance the surgeon requires at the moment. Ordinarily, First Assist is a trained nurse, PA, or another physician. Under the right circumstances, however, it may also be a student. Yesterday the tumblers clicked into place and I was in the right place at the right time.

Now, before this begins to sound "important," in point of fact, I didn't actually participate in the sense I cut this (aside from sutures) or pulled on that (aside from retractors). Still, having an extra set of hands can be helpful and mine were eager to be put to good use. From a student's perspective, you're assisting, even in small ways, and that's always better than observing or merely standing by, all scrubbed up with nowhere to go and nothing to do when you get there.

And the word gets around. You've done the job once, you were attentive and diligent,
you didn't screw up, the doctor seemed to enjoy your company; he'll tell other docs and you'll get to do it again. The more often you do, the better you'll get, and sooner or later, someone may hand you a scalpel, which to your inexperience feels like a Bowie Knife, and say, "You make the first cut."

Are my hands ever eager.


(Creative Commons image by Army Medicine via Flickr)

Saturday, October 15, 2011

Noticing

Babe and farmer hoggettWhen the dogs and I stepped out of the house this morning, the lane was littered with oak, elm, and magnolia leaves so thick our feet (my feet, their paws) barely touched the blacktop as we walked along. It rained last night, not a gentle, soaking, spring-like shower I imagine makes the trees lift their limbs and whisper to one another, "Psst, pass the soap, will you?" This one was intermittently wind-blown and down-pouring, scattering leaves and drenching the countryside. It was the kind of rain that rinses the air clean as a whistle and whets sunlight sharp as a tack.

As we walked up the road, morning business on our minds, something unusual caught my eye. A single leaf, a tiny piece of oaken gold, hung spinning in mid-air, its stem caught in a single strand of spider web, like an arboreal ballet dancer dancing as though her moment had come and never would again. I'm reminded of the line by Mark Twain, Sing like no one's listening, love like you've never been hurt, dance like nobody's watching, and live like it's heaven on earth? That's what she was doing, drifting and swaying to music beyond my hearing. I was mesmerized.

Some people never notice the things that render life more than a matter of getting by, those side-long, fleeting instants when eternity opens a window, reaches through, and taps us on the shoulder. Sort of like what happens in the film, Babe (1995) with James Cromwell as
Farmer Hoggett, a man who notices. Hoggett lives on a sheep farm in Queensland, Australia, and to his family, he seems a bit odd now and then. They're solid, ordinary people who are nevertheless, completely unaware that eternity has not only opened a window, it's climbed through the frame, unpacked its bags, and taken over the guest room.

Hogget knows something is happening. He can't explain it, neither does he bother to try; some things you try to explain and their significance gets lost in the details. He simply lets it all in and follows its lead. Presented with possibilities others would dismiss, he can't help but take them seriously,


For instance, when he notices how Pig interacts with his sheep, he allows the little guy a chance to prove himself. Hoggett sees what no one else can or will, and while he's a man of few words, his actions are as pregnant as a woman at nine months who;s about to pop. Only he doesn't just notice things, he responds to them, opening a creative space in which they can unfold at their own pace. We're often in such a hurry to find out things will turn out, perhaps because we're in doubt they will, that we forget about everything that comes before. Hoggett's efforts are ridiculed, of course, even by his family. But then comes the final scene, when the crowd that jeered goes crazy, cheering its heart out over the little pig that could.


Hoggett knew what Pig was capable of because he'd witnessed it. He noticed something unusual and instead of blowing it off as nonsense, he did what most of us are too afraid or too embarrassed to do, he gave it credence. He did the hard thing and in the end, he wasn't disappointed. It really all begins with noticing.



(Creative Commons image by Lord Mariser via Flickr)


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Friday, October 7, 2011

Missing Megan Fox


Transformers: Revenge of the Fallen
I really like Megan Fox, but not necessarily for the reasons you might think, me being a guy and all. Sure, she's drop-dead gorgeous -- I'd have to be blind as a bat not to have noticed and trust me, I've noticed. But what I like about her so much is her role in the first two Transformer films. No, I'm not talking about the cutoff jean shorts she wears in both, though I noticed them as well. I mean her character.

Megan (if she's reading this, I hope she doesn't mind the familiarity) plays Mikaela Banes, a pretty young woman with a past. Her father has a prison record for grand theft auto and she, a juvenile record for having been his presumed accomplice. She has another liability, however, and that's her beauty and sex appeal. Like far too many women, she has a history of being regarded as a trophy.

In the first film, her boyfriend is a muscular, good-looking, football player who treats her like a possession once too often. She knows there's something wrong with the guys she's chosen to date, she doesn't like the pattern, and she has sufficient inner strength to do something about it. As she's walking home, along comes the film's hero, Sam Witwicky. Sam is everything the other guys could never be: overtly insecure, honest, and down deep, utterly courageous.

In the first installment of the trilogy, Mikaela is not only a match for Sam, in some ways she is even more heroic. For instance, when they're attacked by a mini-decepticon, she grabs a power saw and goes to work, rescuing him. During the final battle against Megatron, she is determined to save Bumble Bee by hooking him up to a tow truck and then drives it backwards down a wreckage-strewn street while he shoots at the bad guys. I love that scene.

In Revenge of the Fallen, her character is a little more traditional and her biggest challenge seems to involve convincing Sam to tell her that he loves her. Sam, how crazy do you have to be to have someone like her around and dither about saying, "I love you?" Get a clue, buddy. Anyway, that bothered me, the fact that she wasn't permitted to be the totally gutsy chick she was in Transformers. Her character wasn't just beautiful, she was admirable.

Now we come to Dark of the Moon and there's no Megan Fox. Instead, we've got a blond babe whom Sam has decided is the love of his life. She flirts with other guys and then minimizes her behavior, she's essentially focused on the accumulation of expensive toys, and perhaps, worst of all, she has absolutely no idea what makes Sam tick. You tell me what's wrong with this picture.

If we wanted to get psychological, we'd have to ask why Sam hooked up with her in the first place. According to the story line, he and Mikaela had a fight, broke up, and rather than do what any man with a lick of sense would do, i.e. turn himself inside out to get Mikaela back, he lets her go. Sam clearly has far too much pride for his own good. It's what kept him from declaring his feelings in Revenge of the Fallen and it comes back to haunt him in Dark of the Moon. We could be Freudian and say the new girl is more like his mother, but we really don't have enough character development to go that route. We do know, however, that Mikaela and his mother are two very different kinds of women and that could explain a lot.

For whatever reasons the producers decided Megan's character wasn't meant to be a part of the last film, I miss her. I liked Mikaela's resourcefulness and willingness to take a risk. Her response to Sam's question, "Fifty years from now, when you're looking back on your life, don't you want to be able to say you had the guts to get into that car?" is one with which I, as an older medical student, can well identify. I also liked the fact that she wasn't squeaky clean. She had a past she was ashamed of but she refused to let that prevent her from something better. Her wounds made her human and more interesting. Best of all, I think, she didn't allow herself to be paralyzed by fear. She could be counted on in the clinches and was capable enough to be a participant in the action rather than a hand-wringing damsel-in-distress. Definitely the right kind of gal and why I'm missing Megan Fox.


(Image of Transformers: Revenge of the Fallen via RottenTomatoes.com)


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Thursday, October 6, 2011

Welcome to Night Float

Night Cityscape 2

It's enough to give a night person an identity crisis. Working night float, that is. Oh, and while we're on the subject, why do they call it night "float," anyway? Does staying up past the witching hour somehow render a person more buoyant? If so, I sure hope it doesn't mean extra mass, too, because, like Scott Calvin (The Santa Clause, 1994), I've tried to be diligent about watching my points lately.


Truthfully, I think "night float" probably does refer to the idea of rising up from the day shift, like a bubble, and floating along its surface from 6 PM to 6 AM. If there are any readers who know the derivation of the phrase, please, feel free to leave a comment. Inquiring minds would love to know -- especially mine.

Anyway, the reason I say it's enough to throw a night person into an identity crisis is, there's nothing like working from sundown to sunup to make you appreciate daylight. When I was younger, I would wake up just as my parents were paging Mr. Sandman. It made trying to get me into bed an interesting proposition sometimes, I'll tell you. But working overnight isn't quite the adventure staying up late once seemed to be.

True, from the perspective of seeing patients in the ER, it's perfect. For reasons I've never quite fathomed, most sickness hits after dinner. Ever notice that? You're fine until 3 AM and then you're hugging the diagonal dimension diver. Partly, we hope whatever has us in its grasp will let go if we just pretend we're fine. Of course, it doesn't, and in days of old, when doctors still made house calls, dad got on the phone while mom mopped our foreheads with a cool washcloth.


Maybe that's the image many of us retain, only now, we have to go to the doctor rather than have her or him come to us. I've heard of a few died-in-the-wool family docs who still get the Jeep out of the garage when it's fifteen below and the snow is piling up like paperwork at tax time, but they're the exception, not the rule. More commonly, folks show up at the emergency room where a medical student like me is waiting, making them wonder if coming to the hospital was such a good idea, after all.

Bushy-tailed and bleary-eyed, I'll introduce myself and explain I'm the first in what will surely feel like the 300 Spartans before we've finished asking the same questions over and over, trying to figure out what the patient already knows: they're sick, otherwise they'd be home in bed, where I'd be too, if I had any sense. We talk, I take their history, do an exam, and then the resident comes along and together we decide what needs to be done. It's a learning experience and one I'm grateful for, but I'm glad last night was my last for a while, because after night float comes morning report.

Morning report is where you realize what sleep deprivation really means. That's when your attending physician asks you the details of the case you admitted the previous evening, only now your brain feels like a bowl of cold oatmeal that has the consistency of cement. The data is there, you're certain of it, because you spent two hours writing up the case. Except what you thought expressed medical brilliance hours before suddenly looks like, "Oh, God, how could I have said that?!" You glance over at your resident who's smiling encouragingly, remembering their own third year and what it's like, being in the hot seat.
Eternity eventually passes, rounds are finished, your attending tells you "good job," and you're left, wondering whether you've got the energy to get home or should you simply fall asleep in your chair. It feels so good, so soft, so nurturing, it would be so easy to just...drift...away...and then your pager goes off.

Welcome to night float.




(Creative Commons image "Night Cityscape 2" by Kent C via Flickr)

Sunday, September 11, 2011

The First Breath of Autumn

Autumn Colors I love mornings like this, early fall maple muffin mornings, with fog as thick as a cloud bank hovering over the hayfield. Freddie the Freeloading porcupine sneaking breakfast under the apple tree, unaware I'm watching. Dew on the grass that will be frost soon enough and air already cool enough to faintly see your breath. It won't last long, the mid-morning sun will see to that.

The first breath of autumn always goes fast.

Kind of like third year rotations. When you're in the starting gate, gazing down the track toward the clubhouse turn (the first curve in horse racing), six weeks appears endless. Before you know it, you're in the home stretch and the written exam lies ahead at the finish line and you're wondering what madness possessed you to think you were too weary to study after a day on the wards. Surely, you didn't need sleep that badly, did you? Yet, somehow, like Seabiscuit, you dig deep, pulling a passing grade or better out of your hat like a magician's rabbit. A weekend of freedom passes like a thief in the night and the process starts all over again

But not this time. At least not with internal medicine. IM is a twelve week test of endurance, though broken into several subgroups you get a wide glimpse at the field. Thus far, I've been on the residents' teaching service, spent eight days with a hospitalist, and Monday heralds rehab medicine. Two weeks later comes two weeks of night float and assuming I'm still afloat after that, my final two with the residents. It's not as long as it sounds, like the first breath of autumn, it goes fast.

At first, the twelve hour days are exhausting and you wonder how the residents do it, how you'll do it when you're one of them. A week and they're familiar, another and they're commonplace while you're hustling to get all your patients seen, clinical notes written and patients seen once more before evening report. If you've had an admission or accompanied a patient to a procedure, you realize this is what cranberries feel like when they're tossed into a blender at Thanksgiving and the switch clicked on.

The good thing is, it's only week six. Instead of feeling like you've just gotten accustomed to finding your way before it's time to move on, you have a chance to actually practice what you've been learning. The context in which you'll see patients will change, but it's still internal medicine. It's not as though you've been doing well-child visits, diagnosing colds, ear aches, and strep throat, and suddenly have to distinguish between major depression and an acute grief reaction. Racing to a code blue cardiac emergency is a bit different from rushing to intervene with a telephone wielding patient who checked self-control at the door to the locked psych unit.

You get used to it, we all do, but it's nice once in a while when you don't have to. When you can to get close to a patient without having say goodbye before hello has barely passed your lips. When you've grown confident walking into a hospital room without a resident holding your hand because you've done it thirty or forty or fifty times and lived to tell the tale. When you can step into the doctors' dictation room, sit down at a computer and do your business because you have business to conduct, just like the other doctors. Don't get too comfortable, though, because it won't last, it can't -- you have other things to learn, other patients to see, and like the first breath of autumn, it all goes fast.

It always does.


(Creative Commons image of autumn colors by franzikus garten via Flickr)

Sunday, August 28, 2011

Peparing for Irene


How do you prepare for a hurricane? Irene has been my first, so I'm hardly an expert, and since most of the so-called "experts" on television weather have been too hysterical to be of much use, I've been on my own. Oh, sure, they invite you to the same song and dance we're heard since 9/11, have plenty of water and food, an emergency radio and flashlights with batteries, and so forth. But I live on a farm which creates its own set of challenges. There's no shelter three blocks away when water starts rising past the crack under the front door.

The first thing I did was cut up all the downed limbs from the last big blast that blew through last week and stack them in the barn. I figured tomorrow morning, after Irene has left me for another boyfriend up the coast, I'll have even more to keep me busy, so why not get a head start. Forewarned is forearmed or, as we say in Scouts, Be Prepared.

Then I finished mowing the pasture that impersonates a yard around my house. With four to six inches of rain in the forecast and the ground still damp from Thursday's showers, any attempt in the near future is going to be muddy. As it is, the Turners -- people who drive down my dead end lane on the presupposition "Dead End" means something other than "there's nowhere left to go," stop when they realize the sign means what it says and turn around on the grass in front of my barn -- have already left deep ruts like a kid carving his initials in fresh cement. No sense in following their lead.

The next step entailed doing something I've been thinking about for the past three winters. I bought a Coleman stove, one of those single burner jobbies that runs on propane. I considered the more compact model that burns white gas but remembered another Scouting lesson: I hate pumping, Coleman white gas powered lanterns and stoves require fairly regular pumping to keep them burning. If this were the dead of winter, I'd have a fire in the fireplace and cooking over it wouldn't be an issue. But in summer? No thanks, I'll take the stove.

After that, it was off to the local grocer for dried pasta, crackers, and cans of soup to heat up with peanut butter sandwiches. Things that are easily prepared with a pot of water and no fuss, no muss. Why peanut butter? Well, if I have to use the propane stove, it's because the power has gone out. With the number of trees looking for a good excuse to tumble down in a heap like a passel of Green Bay Packers on John Elway (if they could have caught him, that is), power outages are worth anticipating. Besides, I like peanut butter.

And that leads me to the apples. Apples and peanut butter. Whole Foods freshly ground honey roasted peanut butter, to be precise. Talk about ambrosia. Well, the apple wars have started early this year, i.e. the annual foray between the crows, worms, wild turkeys, deer, Freddie, and me, for apples from the ancient trees someone planted here long ago. Who's Freddie? He's a porcupine who rents the space under my barn, though if you ask him, he'd say he owns it. Whatever. Drives the dogs absolutely bananas when he ambles across the front yard at night. I saw him crossing the road yesterday, aiming for a mid-afternoon snack. I called what I felt surely was a pleasant enough greeting, but the little introvert turned round and trotted (I didn't know he could move that fast) back home. Feeling badly because I'd deprived him of the same pleasure I enjoy, I tossed a few nibbled cores and some new ones near his front door. I hope he doesn't mind my fingers.

And that brings me back here. The apples are in the kitchen, sharing the side board with fresh brownies, maple muffins, and chicken cooling for tonight's candle light picnic. All that's left is to write my supervisor and tell him I won't be in the hospital tomorrow, and depending on how badly Irene batters my neck of the woods, maybe not the day after. Last year a white pine with a diameter the length of a meter stick fell across the road and we were landlocked for 48 hours. With only one route to the rest of the world, all it takes is one big tree and a hurricane is turned into an adventure, and I'm ready.


(Photo of apple tree copyright 2011 by the author)

Thursday, August 25, 2011

A Little Boy's Dream

I was four years old when my love affair with fire trucks began. At the time, it was a pumper with a hook and ladder truck and an ambulance that caught my eye just before Christmas. I still have them, battered and scarred with parts missing from good times. I wish I'd taken better care of them since they're worth many times more than what my parents paid on the collector's market. Not that I'd sell them, because, well, you know, they're a part of my childhood. For everything else there's MasterCard. You can't buy memories -- not like these, anyway.

On that Christmas morning, though, I was in for a bit of a disappointment. The only sets left on the shelf were ones without the ambulance and I really wanted the ambulance most of all. How else can you rescue the people, I thought? Someone has to take them to the hospital because they've been hurt in the "fire." It was a childhood fantasy I later fulfilled as an adult when, in my first pastorate, I volunteered as an ambulance driver. Little did I know, either then or as a four year old, I'd end up a medical student seeing patients in a hospital. The most amazing things creep up on you when you're least expecting them.

Kind of like another little boy's dream, the one you see in the photo. It's a 1936 Chevrolet I saw a few nights ago, parked in front of the Knights of Columbus in Old Town, Maine. Of course, I had to stop and take pictures. How could I not? My guide for the best tour I could have asked for, was a tow-headed little guy about seven or eight years old who happily indulged me by climbing into the back to ring the bell. He was able do that, you see, because his daddy, as he proudly informed me, owned it.

Old Town has a special connection for me which I discovered the same evening, when I noticed a sign on its outskirts identifying it as the home of Old Town Canoes. We paddled Old Towns when I was a Scoutmaster on white water canoeing trips in Southeastern Oklahoma. And there I was, driving through the place where they were made. I don't know, it just struck me as sweet, and it brought back very pleasant memories of sunburns, campfires, and friends far away.

Anyhow, back to the fire truck. Walking around it I noticed a plaque that told me everything I needed to know about the person who owned it and why. If you look closely you can see it, right there on the passenger side. It reads simply, A Little Boy's Dream. Yeah, you guessed it. Daddy wanted a fire truck when he was was young and promised himself one day, when he was all grown up, he'd have one for his very own. And now he does and he shares it with his son.

Who shared it with me.


(Photo copyright 2011 by the author)

Wednesday, August 24, 2011

Doctor's Notes


Before going much further, I feel like I should apologize for not having written anything lately. The past seven and a quarter days I've been working with the hospitalist service and that includes the weekend. It's probably self-indulgence, but truthfully, our work as students doesn't end with a punch of the time clock. Anyway, thanks, as always, to any and all who've come by to see if there's anything new. I've got the next four days off and I'll try my best to make up for my laxity of late.

What's that? Oh, the hospitalist service refers to physicians who are employed by a hospital for the sole purpose of providing inpatient care. My current rotation entails spending a week to ten days working with one of them -- it's a bit like an apprenticeship -- and learning internal medicine under their tutelage. The two weeks prior were spent with family medicine residents seeing their assigned patients and it's to their service I'll report once again this coming Monday.

As healthcare delivery has changed over the years, it's pretty rare to see a family doctor or any kind of doctor, for that matter, admitting and then following their own patients in the hospital. There are still a few, mostly family practitioners in the hinterlands of upstate Maine or other remote locations, who do it the old-fashioned way, but they're a vanishing breed. For the most part, patients are evaluated in the ER and then transferred to the responsibility of a hospitalist who oversees their hospital stay.

And that's where my fellow students and I come in. We'll report to the Emergency Room, take a detailed history from the patient and/or their family members, complete a physical exam in the company of a resident or attending physician, and then become a member of their treatment team as long as they're inpatient. Sometimes the H & P (history and physical) has already been done when we arrive for rounds (morning report) and we just go on from there.

My first two weeks I spent learning how to write a clinical note. That may not sound like much, but really, it's huge. The clinical or chart or progress note -- they're all basically the same thing -- is how doctors talk to one another about a patient's condition, symptoms, and so forth. Even though I got the basic format down during my psychiatric rotation, writing a note for internal medicine takes practice and I practiced a lot. I didn't have nearly as many patients to follow as I did this past week, so I had time to write and rewrite my notes over and over to make sure I had something worth leaving in the chart.

This past week my task was slightly different. Having gotten accustomed to writing notes that were legible and covered all the clinical bases, now I had to figure out how to turn them out faster in order to keep up with my attending. But you can only write so fast before legibility gets tossed out the window and a student's note has to be readable in order for a supervisor to evaluate our thinking process. So, you learn the art of brevity, writing what is truly necessary, and generating a plan of treatment that specifically addresses a patient's symptoms that particular day. Pragmatics take precedence over literary perfection.

It's a matter of taking one step after another, one step at a time. That's really how a rotation like this one unfolds. To be of any value at all, you've got to be able to communicate about patients and since your note is a critical element in the process, you start there. It's not dramatic, no one's going to page you at the end of the day with an offer of a guest spot on Gray's Anatomy. But once in a while, an attending reads what you've got to say, decides you have a good idea, and adds the medication you suggested or obtains the consult you recommended. And right then, you got to do something good for someone. And that's really cool.


(Creative Commons image entitled "Doctor's Note" by keitamiyoshi via Flickr)
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